Workers' Compensation Forms

Application for Independent Medical Review - DWC Form IMR

Arbitrator Application

Audit Referral Form - DWC AU 906

Compromise and Release - DWC-CA 10214-c

Compromise and Release - third party - DWC-CA 10214-e

Declaration of Readiness to Proceed - DWC-CA 10250.1

Declaration Pursuant to Labor Code Section 4906(g)

Description of Employee's Job Duties - DWC - AD 10133.33

Document Separator Sheet - DWC-CA 10232.2

EDEX Subscriber Application

Employers Report of Occupational Injury - FORM 5020

Independent Medical Review Application - DWC 9768.10

Lien Conference Disposition - WCAB 27

Medical Mileage Expense Form (for Travel on or after 1-1-14)

Medical Mileage Expense Form (for Travel on or after 1-1-15)

Medical Mileage Expense Form (for Travel on or after 1-1-16)

Medical Provider Network Complaint Form - DWC 9767.16.5

Notice and Request for Allowance of Lien - WCAB 6

Notice of Employee Death - DIA 510

Notice of Offer of Regular, Modified, or Alternative Work - DWC - AD 10133.35

Notice of Personal Chiropractor or Personal Acupuncturist - DWC 9783.1

Petition Appealing Administrative Director’s Independent Medical Review Determination

Petition for Appointment of Guardian Ad Litem and Trustee - DIA WCAB 8

Petition for Change of Primary Treating Physician - DWC Form 280 (Part A)

Petition for Commutation of Future Payments - DWC WCAB 49

Petition for Reconsideration - DWC/WCAB Form 45

Petition for Suspension or Revocation of a Medical Provider Network Form (Part A) - DWC 9767.17.5 (A)

Petition for Suspension or Revocation of a Medical Provider Network Form (Part B) - DWC 9767.17.5 (B)

Petition to Reopen - DWC WCAB 42

Petition to Terminate Liability for Temporary Disability Indemnity - DWC/WCAB Form 46

Pre-Trial Conference Statement - WCABF 24

Pre-Trial Conference Statement Lien Issues Addendum - WCAB 24.1

Predesignation and Notice of Predesignation of Personal Physician - DWC 9783

Qualified Medical Evaluator Complaint Form

Replacement Panel Request - QME 31.5

Report of Suspected Medical Care Provider Fraud - DWC Form SMBFR 1115

Request for Accommodations by Persons with Disability - DWC 5

Request for Additional Panel QME (Represented) - Proof of Service

Request for Additional Panel QME (Unrepresented) - Proof of Service

Request for Authorization for Medical Treatment - DWC RFA

Request for Consultative Rating - DWC-AD 104

Request for Dispute Resolution Before Administrative Director - DWC-AD Form 10133.55

Request for DWC Authorization Number - DWC AD-3

Request for Factual Correction of an Unrepresented Panel QME Report - QME 37

Request for Independent Bill Review - DWC IBR 1

Request for Public Records

Request for Reconsideration of Summary Rating - DWC AD 103

Request for Replacement Panel (Represented) - Proof of Service

Stipulations with Request for Award

Stipulations with Request for Award (Death)

Stipulations with Request For Award (For Injury On Or After 1-1-2013) - DWC-CA 10214-a

Substitution of Attorneys - DWC WCAB Form 36

Verification - Application for Discrimination Benefits

Verification - Petition Appealing Administrative Director's IMR Determination

Verification - Petition for Benefits for Serious and Willful Misconduct

Workers Compensation Claim Form - DWC 1